Acute Lower-Extremity Ischemia in a Patient with COVID-19.

BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), which has become a global pandemic. The typical symptoms are fever, cough, and shortness of breath, but the disease can present with atypical signs, including those associated with a hypercoagulable state. These signs include deep venous thrombosis, pulmonary embolism, ischemic stroke, and acute coronary syndrome. Herein, we present the case of acute bilateral lower-extremity ischemia as a thromboembolic complication in a patient with COVID-19. CASE REPORT A 76-year-old woman presented with acute bilateral lower-extremity ulcerations covered with eschar formation of several weeks' duration. During her hospital course, she underwent a test for COVID-19 and the result was positive. An angiogram of the patient's lower extremities showed occlusions of the right distal posterior tibial artery, right mid-distal anterior tibial artery, right dorsalis pedis artery, left mid-distal anterior tibial artery, left dorsalis pedis artery, and left popliteal vein. Tissue plasminogen activator was administered to treat the occlusions. On the following day, the patient had an acute decline in her neurologic state and was emergently intubated. A computed tomography scan of the brain confirmed a subarachnoid hemorrhage requiring reversal of tissue plasminogen activator. The patient was transitioned to comfort care and ultimately died. CONCLUSIONS In conclusion, acute limb ischemia should be acknowledged as a rare complication associated with COVID-19. It is important to raise awareness of arterial thrombosis as a possible complication of the hypercoagulable state caused by SARS-CoV-2 because prompt recognition is essential for early diagnosis and treatment. These actions could have a significant impact on patients' overall outcome.

Subarachnoid hemorrhage and COVID-19: Association or coincidence?

ABSTRACT: Some evidences suggest the involvement of the central nervous system in patients infected with SARS-CoV-2. We aim to analyze possible associations between coronavirus disease 2019 (COVID-19) pandemic and spontaneous subarachnoid hemorrhage (SAH), in a comprehensive neurological center.We conducted a retrospective case series of 4 patients infected by COVID-19, who developed spontaneous SAH. Clinical data were extracted from electronic medical records.Between March 24, 2020, and May 22, 2020, 4 cases (3 females; 1 male) of SAH were identified in patients infected with SARS-CoV-2, in a comprehensive neurological center in Brazil. The median age was 55.25 years (range 36 -71). COVID-19-related pneumonia was severe in 3 out of 4 cases, and all patients required critical care support during hospitalization. The patients developed Fisher grade III and IV SAH. Digital subtraction angiography (DSA) was performed in 3 of the 4 patients. However, in only 1 case, an aneurysm was identified. Inflammatory blood tests were elevated in all cases, with an average D-dimer of 2336 µg/L and mean C-reactive protein (CRP) of 3835 mg/dl The outcome was poor in the majority of the patients, with 1 death (25%); 2 (50%) remained severely neurologically affected (mRS:4); and 1 (25%) had slight disability (mRS:2).This study shows a series of 4 rare cases of SHA associated with COVID-19. The possible mechanisms underlying the involvement of SARSCoV-2 and SHA is yet to be fully understood. Therefore, SHA should be included in severe neurological manifestations in patients infected by this virus.

Spontaneous subarachnoidal hemorrhage in patients with Covid-19: case report.

In this article, subarachnoidal hemorrhage developing in a case with Covid-19-related pneumonia was evaluated. In the presence of respiratory system infection signs such as cough and weakness in patient who present with sudden loss of consciousness, performing lung imaging as well as performing brain computerized tomography scan can allow the detection of an underlying Covid-19 infection.

The Perioperative Management of Subarachnoid Hemorrhage During the Coronavirus Disease 2019 Pandemic in China.

BACKGROUND: For most of the international community outside the epicenter, coronavirus disease 2019 (COVID-19) containment is normalizing, and daily medical practice runs parallel to preventing and treating COVID-19. This experience of simultaneously conducting emergent surgery and infection control for COVID-19 disease is useful outside the epicenter during the pandemic. CASE DESCRIPTION: In this single-center retrospective observational study, we enrolled patients with subarachnoid hemorrhage (SAH) who were emergently admitted from January 23 to April 8, 2020. Based on the COVID-19 triage, patients with SAH were divided into 3 categories: positive, negative, and under investigation. During 77 days, 90 patients with SAH were admitted at the center. The median age was 55 years (range, 18-80 years) and 40 patients (44.4%) were male. None was positive, 42 patients were negative, and 48 patients were under investigation for COVID-19 before surgery. During the same period, 9 patients were diagnosed with COVID-19 without nosocomial infection. CONCLUSIONS: Rescuing patients with SAH and containment of COVID-19 benefit from joint prevention and control, a centralized system of equipment distribution and personnel assignment, and quick workflow establishment.

Hepatitis B virus induced cytoplasmic antineutrophil cytoplasmic antibody-mediated vasculitis causing subarachnoid hemorrhage, acute transverse myelitis, and nephropathy: a case report.

BACKGROUND: Transverse myelitis, subarachnoid hemorrhage, and nephropathy are established but rare complications of hepatitis B virus infection that can potentially be triggered by an antibody-mediated vasculitis as a result of a viral infection. The following is a case report detailing a patient presenting with all three of the above presentations who is cytoplasmic antineutrophil cytoplasmic antibody-positive and a chronic carrier of hepatitis B. CASE PRESENTATION: A 33-year-old Nepalese man presented to our hospital with headache, swelling of his body, paraplegia, and back pain that developed over a period of 10 days. Laboratory studies showed proteinuria and elevated levels of serum urea and creatinine. Viral serology was suggestive of chronic inactive hepatitis B carrier state. A computed tomography scan of his head revealed features suggestive of subarachnoid hemorrhage. Magnetic resonance imaging of his dorsal spine showed diffuse T2 high signal intensity within his spinal cord extending from second to 12th thoracic vertebral level which was suggestive of transverse myelitis. The origin of these symptoms was attributed to immune complex-mediated vasculitis after serum analysis for cytoplasmic antineutrophil cytoplasmic antibody came out positive. He was managed with steroids administered orally and intravenously and entecavir administered orally. CONCLUSION: This case highlights the possibility of a hepatitis B virus-induced vasculitis as the cause of subarachnoid hemorrhage, transverse myelitis, and nephropathy.

Fatal subarachnoidal haemorrhage in a Norwegian traveller with dengue virus infection.

We present a Norwegian female in her thirties who acquired dengue fever caused by dengue virus serotype 2 while travelling to Mexico. When hospitalised 3 days after symptom onset, the patient had severe headache, fever, rash and a positive tourniquet test, but did not fulfil the criteria of dengue haemorrhagic fever (DHF). Five days later she developed a fatal subarachnoidal haemorrhage. A post-mortem examination failed to reveal any intracranial arterial aneurysm. Our case was consistent with so called 'dengue fever with haemorrhages', a recently described entity that mainly affects adults and may cause severe bleedings also in the absence of DHF.

Subarachnoid hemorrhage and diffuse vasculopathy in an adult infected with HIV. Case report.

This 34-year-old man with a 10-year history of HIV infection presented with an acute onset of severe headache, fever, nausea, vomiting, and left-sided weakness. Computed tomography (CT) scanning demonstrated diffuse subarachnoid hemorrhage (SAH), and subsequent CT angiography revealed multiple large and giant intracranial aneurysms with diffuse vasculopathy. The patient's CD4-positive cell count was low, although he had been receiving combination antiretroviral therapy and his viral load was undetectable. The preponderance of the literature on HIV-infected patients with intracranial vascular involvement has concerned children in whom there is a high viral load. In such children, appropriate antiretroviral therapy may result in the complete resolution of these vascular abnormalities. In the present study, the authors report on the unique case of an HIV-infected adult patient who presented with SAH, diffuse intracranial vasculopathy, and multiple giant and fusiform aneurysms, despite having received adequate antiretroviral treatment and demonstrating an undetectable viral load. Intracranial vascular involvement in these patients may become increasingly common as the management of HIV infection continues to improve and afflicted patients survive for longer periods.